Basic Information
| Provider Information | |||||||||
| NPI: | 1548469174 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCED FACULTY ASSOCIATES MEDICAL GROUP INCORPORATED | ||||||||
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| OtherOrganizationName: | MFA MEDICAL GROUP GATEWAY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3768 | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953443768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097257149 | ||||||||
| FaxNumber: | 2097260259 | ||||||||
| Practice Location | |||||||||
| Address1: | 378 W OLIVE AVE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953483182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097257560 | ||||||||
| FaxNumber: | 2097257561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2007 | ||||||||
| LastUpdateDate: | 07/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | SHAW | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2097231920 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | GR0041481 | 05 | CA | MEDI-CAL GROUP NUMBER | MEDICAID | CS1342 | 01 | GA | RAILROAD MEDICARE | OTHER | ZZZ09267Z | 01 | CA | BLUE SHIELD GROUP NUMBER | OTHER |